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[Empyema thoracis accompanied by hyperammonemic encephalopathy]
N Kuze1, Y Nishizaka, K Okamoto
1Department of Respiratory Medicine, Osaka Red Cross Hospital, Japan.
Summary
A patient with altered consciousness had severe hyperammonemia due to a pleural space infection with urease-producing anaerobes. Treatment with antibiotics and pleural drainage improved neurological status and ammonia levels.
Area of Science:
- Infectious Diseases
- Neurology
- Pulmonology
Background:
- Consciousness disturbance can stem from various underlying conditions, including metabolic encephalopathies.
- Hyperammonemia, a condition of elevated ammonia levels, is a known cause of altered mental status.
- Pleural effusions are typically associated with respiratory or systemic illnesses, rarely with neurological compromise.
Observation:
- A 50-year-old male presented with coma and normal brain CT, but massive right-sided pleural effusion.
- Purulent pleural fluid culture identified urease-producing anaerobes, including Bacteroides fragilis.
- Markedly elevated serum ammonia (586 µg/dL), white blood cell count, and C-reactive protein were noted, with preserved liver function.
Findings:
- The patient's consciousness improved following antibiotic therapy and pleural drainage.
- Neurological recovery correlated with decreasing serum ammonia and C-reactive protein levels.
- The absence of other metabolic derangements pointed to the pleural infection as the source of hyperammonemia.
Implications:
- This case highlights a rare cause of hyperammonemic encephalopathy originating from a localized anaerobic pleural infection.
- It underscores the importance of considering non-hepatic causes of hyperammonemia in patients with altered consciousness and infection.
- Prompt diagnosis and management of pleural infections are crucial to prevent severe neurological complications.